AIDS & Clinical

Jafari et al., J AIDS Clinic Res 2012, 3:6

http://dx.doi.org/10.4172/2155-6113.1000160

Research
Research Article

Open Access

Otolaryngological Manifestations in HIV Infected Patients, Tehran, Iran

Sirous Jafari1, Ebrahim Razmpa2, Zaker Saeedinejad3, Mosa Sadrhosseini2, Koosha Paydary3,5, Behtash Saedi2, Gholamreza Esmaeeli Djavid3,
SeyedAhmad SeyedAlinaghi3*, Maryam Foroughi3 and May Sudhinaraset4
Department of Infectious and Tropical Diseases, Tehran University of Medical Sciences, Tehran, Iran
Department of Otolaryngology, Tehran University of Medical Sciences, Tehran, Iran
3
Iranian Research Center for HIV/AIDS (IRCHA), Tehran University of Medical Sciences, Tehran, Iran
4
Health Systems Initiative, Global Health Group, University of California, USA
5
Students Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
1
2

Abstract
Background: Extant literature finds that 80% of HIV-infected patients present with otorhinolaryngological
symptoms during the course of the infection. To date, no studies have defined HIV-associated ENT manifestations
in Iran. To fill this gap in the literature, this study characterizes ENT signs and symptoms in HIV-infected individuals
in Tehran, Iran.
Methods: The cross-sectional study consisted of 98 HIV infected patients who were referred to a Voluntary
Counseling and Testing (VCT) center of Imam Khomeini hospital, Tehran from September 2007 to September
2008. A detailed history and physical examination was conducted for each patient. A questionnaire based on ENT
manifestations was designed for the study. Para clinical assessments were carried out if any ENT manifestation was
present. Analysis included calculations of mean values of quantitative associations between ENT symptoms and
otological and nasopharyngeal complaints as well as ENT symptoms and demographic characteristics. Statistical
analysis was estimated using either Chi-square test or t- test.
Results: Among ENT manifestations, otological and nasopharyngeal complaints were most common. Hearing
loss (61%), post-nasal discharge (23.5%), xerostomia (39.8%) and voice change (23.5%) were the most frequently
cited complaints by participants. In clinical examination, external otitis (6%), mucosal dryness of nasopharynx
(6.1%), candidiasis (9.2%), posterior (7.1%) and anterior (6.1%) lymphadenopathies were also common findings.
Lower CD4 count was associated with increased prevalence of oropharyngeal conditions. In addition, the duration
of HIV infection was significantly associated with oropharyngeal conditions.
Conclusion: ENT evaluations are highly recommended for early diagnosis, especially in patients with specific
symptoms in unusual locations.

Keywords: ENT manifestations; HIV infection

Introduction
The link between ear, nose and throat (ENT) disease and human
immunodeficiency virus (HIV) has been well-established. Studies
have found that over 80% of HIV-infected individuals present with
otorhinolaryngological symptoms during the course of infection [13]. In early stages of the infection, oral and nasal manifestations are
highly common, and typically diagnosed before HIV has been detected
[4]. Oral disease, in particular, is the most common, occurring in
approximately half of HIV positive patients [5]. Due to high incidence
of HIV worldwide, combined with comorbidity associated with ENT
symptoms, ENT specialists and otolaryngologists play a crucial role
in diagnosis and treatment of HIV infected patients. Early studies
demonstrate that ENT symptoms may result in HIV, are associated with
progression as well as treatment failure of HIV [6-10]. Therefore, while
ENT symptoms are not diagnostic of HIV, it may suggest infection,
and ENT specialists should be equipped with knowledge of ENT
manifestations associated with HIV [11].
The HIV lymphadenopathy and lymphoid hyperplasia associated
with the immunocompromised state may be observed as a consequence
of viral dissemination. Although complications of external ear
commonly arise from infections such as Pneumocystis or Tuberculosis,
sensorineural hearing loss may result from primary involvement of the
central nervous system (CNS) or peripheral auditory nerve. Thereby,
pathological mechanisms responsible for such manifestations are either
related to opportunistic infections or malignancies associated with the
immunocompromised state in HIV patients [7-10].
J AIDS Clinic Res
ISSN:2155-6113 JAR an open access journal

To date, no previous study has been conducted to determine HIVassociated ENT complications in Iran. Therefore, the aim of this study
was to identify the prevalence of ENT complications in HIV infected
people in Iran. In addition, we wanted to determine the associations
between ENT manifestations, demographic characteristics such as age
and gender, and therapeutic features including CD4 count and being on
highly active antiretroviral therapy (HAART).

Methods
Study participants
From September 2007 to September 2008, 98 HIV-infected patients
were recruited to participate in a cross-sectional study. Recruitment
took place at the Voluntary Counseling and Testing (VCT) center
of Imam Khomeini hospital, Tehran. All participants attended
an outpatient ENT clinic where they underwent examination by

*Corresponding author: SeyedAhmad SeyedAlinaghi, MD, Iranian Research Center for HIV/AIDS (IRCHA), Tehran University of Medical Sciences, Tehran, Iran, Tel:
+98(021) 66947984; Fax: +98(021) 66947984; E-mail: s_a_alinaghi@yahoo.com
ReceivedApril 04, 2012; Accepted June 28, 2012; Published July 04, 2012
Citation: Jafari S, Razmpa E, Saeedinejad Z, Sadrhosseini M, Paydary K, et al.
(2012) Otolaryngological Manifestations in HIV Infected Patients, Tehran, Iran. J
AIDS Clinic Res 3:160. doi:10.4172/2155-6113.1000160
Copyright: 2012 Jafari S, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.

Volume 3 Issue 6 1000160

Citation: Jafari S, Razmpa E, Saeedinejad Z, Sadrhosseini M, Paydary K, et al. (2012) Otolaryngological Manifestations in HIV Infected Patients, Tehran,
Iran. J AIDS Clinic Res 3:160. doi:10.4172/2155-6113.1000160

Page 2 of 4
Categories

Otological

Nasopharyngeal

Oropharyngeal

Symptoms and Hearing loss, pruritus and tinnitus Post nasal discharge and rhinorhea Xerostomia and
complaints
Sore throat
Clinical findings External otitis

Mucosal dryness and crusting

Laryngeal

Head & neck

Voice change

Candidiasis and gingivitis -

Posterior and anterior lymphadenopathy

Table 1: Common ENT symptoms and clinical findings observed among study participants, Tehran, Iran.
ENT manifestations

Demographic/therapeutic features of patients

All (n=98)

With the manifestations Without the manifestations *P value

Otological

Male
Female

78.3%

100%

72.7%

21.7%

0%

27.3%

Duration of HIV infection (months)

31.46 27

14.32 22.78

30.62 32.78

0.032

CD4 level (cells/ml)

310.89 294.9

163.18 218.6

353.64 301.42

0.007

Age

35.76 11.2

30.34 16.27

37.06 9.27

0.018

Male
Female

80.6%

57.9%

86.1%

19.4%

42.1%

13.9%

Oropharyngeal
Head and neck

0.027

0.005

*Only significant P values are mentioned defined as p<0.05

Table 2: Statistically significant associations between individual-level factors and ENT manifestations in three parts (otological, oropharyngeal, head and neck).

otorhinolaryngologists three times a week. Standard western blot test

was performed to confirm HIV status.

complaints including hearing loss, otalgia, otorrhea, external canal

pruritus, tinnitus, vertigo and otorrhagia.

Measures

Examination of the external auditory canal in 67 patients, showed

external otitis (6%), otomycosis (3%) and mass (1.5%) was observed.
Among the 43 patients for whom the tympanic membrane examination
was assessed, 34 patients (79.1%) had normal tympanic membranes,
and in one study participant, otitis media with effusion (OME), chronic
otitis media (COM) and retracted tympanic membrane were found.
Audiometry tests were performed for perforated, retracted, OME,
COM and otorrhagy. SDS (speech discrimination score) and SRT
(speech recognition testing) were performed among 11 participants,
and all reported within clinical normal ranges. Additionally, right and
left tympanogram typing were requested for these 11 patients. The right
tympanogram was found A type in almost all patients (n=10) and C
type in one patient. Similarly, almost all patients (n=9) was A type in
the left tympanogram, with one patient each resulting in B and C type.

A standard questionnaire regarding ENT manifestations was

filled by an ENT specialist after each participant examination. If any
ENT manifestations were identified, para clinical assessments (e.g.
audiometry, peripheral nervous system (PNS) CT scan) were carried
out. Detailed clinical history was taken and physical examinations were
conducted. Demographic characteristics and laboratory tests were
obtained via patient interview and profile.

Data analysis
Mean values for quantitative variables (age, CD4 count and duration
of infection) and the frequency of qualitative data (sex, presence or
absence of ENT manifestations and taking or not taking HAART) were
analyzed. Quantitative data were reported with SD of their mean
values and qualitative data were calculated as relative and absolute
prevalence rates. P values less than 0.05 were considered statistically
significant. All analyses were performed using SPSS version 12. Statistical
analysis was estimated using either Chi-square test or t- test.

Ethical considerations
Informed written consent was obtained from all participants. This
study was approved by the Institutional Review Board (IRB) of Tehran
University of Medical Sciences.

Results
Of the 98 study participants, approximately 81% were men
(n=79). The mean age of participants was 35.7611.2 years. Of these,
41 patients (41.8%) had previously been on HAART and the mean
duration of diagnosis was 31.4627 months. The mean CD4 count was
310.89294.9 cells/ml, and in 42.9% of the patients, CD4 count was
less than 200 cells/ml. Clinical and paraclinical findings were assessed
in ear, nose and sinuses, mouth and oropharynx, larynx and neck. Of
these otorhinolaryngological symptoms, nasal and oral complaints
were the most common among the patients. Table 1 shows the most
prevalent complaints and clinical findings among patients.

Nose and sinuses

Eighty-five percent of study participants presented with nasal and
sinus symptoms and 75.5% had nasal and sinus complaints including
rhinorrhea, nasal discharge, facial pain, epistaxis, nasal obstruction,
post-nasal discharge, anosmia and hyposmia. Discharge was observed
in 23 of the patients (23.5%). Other clinical findings included mucosal
dryness (6.1%), crusting (5.1%), edema (4.1%) and septal perforation
(1%). In the case of septal perforation and nasopharynx edema (n=5),
PNS CT was performed and rhinosinusitis was found in only one
patient. Nasopharyngoscopy for all patients were normal.

Mouth and oropharynx

A majority of patients tested positive for oral and oropharyngeal
clinical manifestations (n=62, 62.2%). Patients indicated xerostomia
(39.8%), repeated sore throat (13.3%), dysphagia (12.2%), burning
tongue (9.2%), odynophagia (8.2%) and other complaints (3.1%).
In physical examinations, study participants showed symptoms of
gingivitis (11.2%), candidiasis (9.2%), aphthous (4.1%), mass (1%) and
others (3.1%).

Otological manifestations

Larynx

Approximately 61% of study participants presented at least one

otological manifestation. Almost all of these participants had ear

Larynx associated symptoms occurred in 45 patients (45.9%).

Voice change (23.5%) and hoarseness (17.3%) were the most common

J AIDS Clinic Res

ISSN:2155-6113 JAR an open access journal

Volume 3 Issue 6 1000160

Citation: Jafari S, Razmpa E, Saeedinejad Z, Sadrhosseini M, Paydary K, et al. (2012) Otolaryngological Manifestations in HIV Infected Patients, Tehran,
Iran. J AIDS Clinic Res 3:160. doi:10.4172/2155-6113.1000160

Page 3 of 4
manifestations; however, nodules and edema were also reported in
7.5% of study participants.

Head and neck

Clinical manifestations of the head and neck were observed in 19
patients (19.4%). Pigmentation and parotid enlargement were reported
in two patients. Fungal infection and solitary mass were observed in
one patient. Lymphadenopathy of the head and neck was observed in 14
patients (14.3%) including posterior cervical (7.1%), anterior cervical
(6.1%), pre auricular (4.1%), posterior auricular (4.1%), occipital
(3.1%), submental (1%), and sub mandibular (1%).
As shown in Table 2, there was a statistically significant difference
between men and women in otological manifestations (p<0.05).
Men demonstrated greater otological findings compared to women.
Another significant difference was observed between CD4 count
and oropharyngeal manifestations. Longer duration of infection was
associated with greater oropharyngeal symptoms. In addition, greater
frequency of head and neck symptoms was positively associated with
age and male gender (p<0.05).

Discussion
To our knowledge, this is the first study to characterize ENT signs
and symptoms among HIV-infected individuals living in Tehran, Iran.
Using a convenience sample from a VCT clinic, we found that the most
common otological symptoms were hearing loss and tinnitus. These
manifestations were observed among 61.2% of study participants,
which is in line with other studies that have reported a wide range
between 11.5%-71.4% among HIV-infected individuals [12-14]. These
results are important for the clinical care of HIV-infected patients.
Providers should be recognize the high prevalence of ENT symptoms
found among this vulnerable population.
External otitis and perforated tympanic membrane were the most
prevalent manifestations meanwhile other studies have demonstrated
recurrent otitis media [15], COM [16] and AOM [17] as common
symptoms among HIV-infected individuals. These data indicate the
need to recognize external otitis and perforated tympanic membrane
manifestations as additional common symptoms. Surprisingly,
underlying sensorineural mechanism was not found to be responsible
for hearing loss detected according to audiometry tests performed.
Other studies have documented sensorineural defects as a pathological
explanation for the common hearing loss observed among HIV infected
patients [18]. One possible explanation for this difference is that study
participants were in the primary stages of infection and therefore,
sensorineural mechanisms were not detected.
Candidiasis is one of the most critical clinical complications
among HIV-infected patients. In this study, gingivitis and candidiasis
were commonly observed; however, other studies have reported
a wide range between 14.6% to 86% [19]. The positive association
between oropharyngeal frequency and CD4 levels may be due to viral
infection progression. There was also a positive association between
oropharyngeal manifestations and chronicity of the infection.
Moreover, results indicate that being on HAART was not associated
with ENT manifestations, which has produced mixed results in prior
literature [20,21]. While some studies have also found no association
between being on HAART and ENT manifestations [20], other studies
have found that HAART may cause a considerable decline in incidence
rate of ENT manifestations due to elevated levels of CD4 count [21].
This study found that age was associated with otological
J AIDS Clinic Res
ISSN:2155-6113 JAR an open access journal

complications among HIV-infected individuals. For example, recurrent

otitis media was frequently observed among HIV-infected pediatric
patients. One hypothesis for this finding is that children experience
depressed cellular immunity and eustachian tube dysfunction [22].
In addition, posterior and anterior cervical lymphadenopathies were
highly common symptoms found among this population, and that
younger individuals were more likely to experience these manifestations
compared elderly patients (p<0.05).
Finally, this study found that gender was associated with presenting
with otological symptoms. Compared to women, men are more likely
to present with a number of otological manifestations [23]. Specifically,
this study found that men were more likely to report nasopharynx
complications, particularly due to post-nasal discharge. The study
found that men were more likely to report head and neck symptoms
compared to women (p<0.05), which has been validated by other
studies [24].
As with any study, there are limitations to our findings. First,
due to the sample recruitment within clinics, these results may be an
underestimation of prevalence of ENT manifestations. Due to high
social stigma of HIV/AIDS in Iran, individuals may be less inclined
to seek out HIV/AIDS diagnosis. Second, the small sample size is also
a limitation of the study. Stratified results of age and gender may not
be powered to produce valid results. Lastly, due to the cross-sectional
nature of the study, causality between ENT and HIV infection could not
be assessed. Incidence of ENT manifestations would best be determined
using a longitudinal study design.

Conclusion
In conclusion, ENT evaluations by clinicians among HIV infected
patients are highly recommended. HIV replication in CD4 positive
cells renders the body more susceptible to opportunistic infections
and neoplastic disorders. Such pathogens spread quickly in the
vulnerable host, resulting in the emergence of uncommon symptoms
and malignancies reported in immunocompromised patients [25-27].
Therefore, further investigations should be required in all complicated
cases, particularly consultations with ENT specialists given the high
prevalence of ENT manifestations. It is particularly crucial to diagnosis
these symptoms early to ensure prompt treatment [28]. Early diagnosis
of HIV infection via recognition of manifestations ensures longer
survival of patients.
It is particularly important to note that ENT conditions may be occur
in both HIV-positive and negative patients; however, specific symptoms
are only reported in unusual locations and in a more aggressive fashion
among HIV-positive infected individuals. Recognition of localized
manifestations of the head and neck may improve the clinicians ability
to diagnose HIV infection clinically and provide the patients with the
best chances for timely and effective treatment.
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Volume 3 Issue 6 1000160

Citation: Jafari S, Razmpa E, Saeedinejad Z, Sadrhosseini M, Paydary K, et al. (2012) Otolaryngological Manifestations in HIV Infected Patients, Tehran,
Iran. J AIDS Clinic Res 3:160. doi:10.4172/2155-6113.1000160

Page 4 of 4
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Volume 3 Issue 6 1000160